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Crps
1.
2. The syndromes appearing under
this include
•Sudeck's atrophy,
•Sympathetic dystrophy,
•algodystophy,
•shoulder-hand syndrome,
•causalgia.
3. What do they have inWhat do they have in
common?common?
• Vasomotor instability
• Trophic skin changes
• Regional osteoporosis
• Pain, OUT OF PROPORTION to the
inciting cause.
• Functional impairment
4. Definition?Definition?
• “CRPS is a multi-symptom, multi-
system, syndrome usually affecting
one or more extremities, but may
affect virtually any part of the
body.”-International Research Foundation
For RSD/CRPS.
5. Historically the signs & symptoms wereHistorically the signs & symptoms were
first recognized by Weir Mitchellfirst recognized by Weir Mitchell
during American Civil War in 1864during American Civil War in 1864
6. EtiologyEtiology
A number of precipitating factors have
been associated with RSD / CRPS including:
•Trauma (often minor) like fractures
•Ischemic heart disease and myocardial
infarction
•Spinal cord disorders
•Cerebral lesions
•Infections
•Surgery
•However, in some patients a definite
precipitating event can not be identified
8. PathophysiologyPathophysiology
•Argued over since it was first described a
hundred years ago.
•It was usually regarded as type of sympathetic
overactivity ,hence the earlier name-Reflex
Sympathetic Dystrophy.
•Now recognised that multiple mechanisms are
involved,,, abnormal cytokine
release,neurogenic inflammation,sympathetic
mediated enhancement of pain responses and
cortical reactions to noxious stimuli..
9.
10.
11. Clinical featuresClinical features
.
Highly variable & difficult to characterize
Sensory Disturbances:
•Pain that is disproportionate to precipitating cause-
hallmark
•Allodynia , hyperalgesia , hyperaesthesia
•Aggravating factors active/passive movement ,
environmental/local temperature changes , dependent
limb position & emotional excitement
16. SPREADING SYMPTOMS
a.An "independent type" where symptoms
spread to a separate, distant region of the
body. This type of spread may be
spontaneous or related to a second
trauma.
b.Total body RSD
c.A "continuity type" of spread where the
symptoms spread upward from the initial
site, e.g. from the hand to the shoulder.
d.A "mirror-image type" where the spread
was to the opposite limb.
17. diagnosis?diagnosis?
Primarily on clinical grounds & then confirmed with objective
tests
Blood studies
WBC count,ESR,C-reactive peptide Inflammatory processes
RF,ANA titres ruling out
Radiography
Soft tissue swelling & osteoporosis
Bone scanning
Triple phase bone scan after i.v radionuclide tracer
MRI
Rule out & narrow the DD or to find out cause
Vasomotor & Sudomotor measurements
Thermography ,sweat outputs-QSART , blood flow , edema
volume
18. Paravertebral Sympathetic Ganglion
Blockade
Most effective & “GOLD STANDARD” in diagnosis of
SMP
Phentolamine Testing
Non-specific alpha antagonist
Safe,simple,less adverse effects
Most practical when more than one limb is affected
Regional intravenous sympathetic
blockade
Common agent--Guanithidine
19. ManagementManagement
Patient education & information
Physical therapy-mainstay of treatment,,,counselling,gain
confidence, motivation,
desensitization&mobilization,strengthening of muscles
Symptomatic relief
For constant pain associated with
inflammation:Nonsteroidal anti-inflammatory agents (e.g.
aspirin, ibuprofen, naproxen, indomethacin, etc).
•Corticosteroids(e.g. methyl prednisolone)
•Calcium channel blockers-pain reduction especially during cold
weather,relaxes smooth muscles ( eg; nifedipine)
For constant pain not caused by inflammation:
• Agents acting on the central nervous system by an atypical
mechanism (e.g. tramadol)
20. For constant pain and sleep disturbances:
o Anti-depressants (e.g. amitriptyline, doxepin,
nortriptyline, trazodone, etc)
For muscle cramps (spasms and dystonia):
o Klonopin (clonazepam)
o Baclofen
Protectives to bone:
o Calcitonin.bisphosphonates,vitamin C
Psychotheray:
o To prevent depression,anxiety & sleep
deprivation
Sympatholysis:
o Topical clonidine-alpha receptor agonist that
inhibit presynaptic release of
norepinephrine,reduces localise
dhyperalgesia
o Oral sympatholysis-alpha blockers
(eg:prazosin,terazoin)